R116 Accident AAIU report discussions

https://www.boards.ie/discussion/comment/118122194#Comment_118122194

It does seem strange to have point number 10 in there. It's almost as if they forgot to remove it.

MrMusician18

https://www.boards.ie/discussion/comment/118122838#Comment_118122838

That's what it looks like to me - that there was another point or paragraph that discussed the crews role and that was removed, but the edit wasn't followed through.

jmayo

The Helicopter was manoeuvring at 200 ft, 9 NM from the intended landing point, at night, in poor weather, while the Crew was unaware that a 282 ft obstacle was on the flight path to the initial route waypoint of one of the Operator’s pre-programmed FMS routes

Can some explain why they were at 200ft 9 Nautical Miles from their landing point ?

Is that one of the SOPs for let down into Blacksod ?

Also an instructor once said to me when he heard someone on the radio state "they were manoeuvring", "What the f does that mean?"

Alun

https://www.boards.ie/discussion/comment/118122996#Comment_118122996

Wasn't it the case that the route they had programmed in was one that was actually originally intended for the refuelling run to and from Blacksod?

lintdrummer

The report has a section about what each crew member had been doing in the days leading up to the accident. They seem to have been on duty since 13:00 on the 13th and most had gone home sometime after 9pm before getting the call to return to duty for the accident flight. Considering they had all been awake since early morning that day (Commander arose at 6.15 am), point 10 is entirely valid. By the time the mission took off the Commander had been awake for just shy of 17 hours.

Now I am only about 10% of the way through reading the report so I don't know if more is made of this point further in, but the facts are represented and the observation in point 10 is valid.

plodder

https://www.boards.ie/discussion/comment/118122828#Comment_118122828

Seems a no brainer to me. If they can supply it, why wouldn't they (going forward)? Or if they won't then some other state agency should. Doesn't seem reasonable to be relying on other countries doing it.

lintdrummer

https://www.boards.ie/discussion/comment/118122194#Comment_118122194

https://www.boards.ie/discussion/comment/118122838#Comment_118122838

https://www.boards.ie/discussion/comment/118122962#Comment_118122962

Just found this on page 320 with regard to the point about fatigue raised above:

Based on the information in the 72-hour activity study, the Commander was likely to have been awake for more than 15 hours at time of tasking, more than 16 hours at time of lift-off and more than 18 hours at the time of the accident. The Co-pilot was likely to have been awake for more than 14 hours at time of tasking, more than 15 hours at time of lift-off and more than 17 hours at the time of the accident. Research indicates that the likely hours of wakefulness for the accident Flight Crew, during the accident flight, meant that they were more prone to making errors, and indeed there is evidence of trapped and un-trapped errors on the CVR. Furthermore, OMF stated that there was a potential for fatigue to set in quicker for the crew of a support SAR helicopter rather than on a SAR helicopter, due to the somewhat monotonous nature of a SAR support mission.

Furze99

https://www.boards.ie/discussion/comment/118122810#Comment_118122810

Yes but Black Rock is rather larger than 90 metres in width!! https://en.wikipedia.org/wiki/Blackrock_Island,_County_Mayo

It's not a small pointy object but a substantial feature - could be 400 metres by 300 metres and higher than Liberty Hall. With a lighthouse perched on top.

MrMusician18

Point 10 can be both valid and irrelevant though. Unless there was a specific error that the crew made because they were tired, then it's not really relevant. I haven't read the full report, so maybe there was such an error, but it seems unusual not to mention it specifically as a contributing factor.

If the crew were well rested, would the accident have have happened? Of course one couldn't say for certain but since the route was set using faulty information and they didn't have the obstacle on it, and visibility was low - I would see it as likely the accident would've happened anyway.

Roger_007

https://www.boards.ie/discussion/comment/118122838#Comment_118122838

I think what they are trying to do is report that there were errors and lapses of judgement which led to the only probable cause of the accident which was:-

“The Helicopter was manoeuvring at 200 ft, 9 NM from the intended landing point, at night, in poor weather, while the Crew was unaware that a 282 ft obstacle was on the flight path to the initial route waypoint of one of the Operator’s pre-programmed FMS routes.”

The report goes on to list a number of contributory factors but these are not ranked in any order of importance.

What the report is really saying that there is no way that the helicopter should have been flying at that altitude and in those conditions while still over 16km from their intended landing point. I think that the report is also saying in point number 10 that, irrespective of other considerations, the flight crew made errors which caused them to be do what they did. I assume that the investigating team, in an effort not to apportion blame to any individual, has not specified precisely what errors or lapses of judgement were made by the flight crew while at the same time being obliged to report that errors were made.

This report does not really explain why the accident happened.

maestroamado

https://www.boards.ie/discussion/comment/118121667#Comment_118121667

I would expect this be normal for new builds as the info in planning and if approved passed on to mapping...

lintdrummer

https://www.boards.ie/discussion/comment/118123261#Comment_118123261

Read the quoted text from the report that I posted again. It says that errors were made and some were trapped and some weren't. You might have a flawed understanding of this kind of investigation. There are always multiple reasons why an accident happens. There is ample evidence here for a degree of fatigue and that may be a contributing factor. It's not going to be black and white like "decision x was made due to fatigue and as a direct result the accident occurred".

All we can say is that they were almost certainly tired and they absolutely made some errors during the flight. If they had been better rested would they have considered the EGPWS warning they got shortly before the accident more carefully? Would they have reacted quicker to the Winchman telling them to come right because there was an island straight ahead? We can't say for certain but in these accidents it's little things that make big differences and the AAIU considered the fatigue aspect important enough to issue recommendations to the operator about how they analise and manage fatigue.

Nijmegen

Unfortunately it's difficult to try and read between the lines of a safety report that has had such a vigorous and apparently costly legal process involved in coming to its conclusions. You could be looking at an obvious gap or just inferring that there's something there because there were legals involved. Hard to say if the original unfettered report might have said more about the crew or not.

Certainly we want to avoid the habit of safety reports ending up in drawn out legal processes like this, and perhaps the state stiffing the families for the bill will be a part of the way to avoid people doing it in the future.

zg3409

I have not yet read full report, however I am familiar with blacksod helipad and the flight route from BlackRock.

Firstly it seems strange if they were heading from Dublin to Blacksod that they would need to go out to Blackrock to come back in. It maybe have been the wind direction as choppers land into the wind, and don't like to fly backwards or turn direction at last minute. Assuming landing from North West to Blacksod was the best route, then the minimum altitude should have been clearly stated and pre-programmed. Minimum altitude is critical to help avoid all objects, and it seems the minimum altitude was not defined. Naturally the minimum altitude will drop as you get closer to landing and typically you want to land in a direction that is clear of any obstacles, but also into the wind. 200ft seems very low, but there may have been cloud or cross winds at higher altitudes. It may also have made seeing the landing lights in Blacksod easier. You don't want to fly through cloud or fog if you can avoid it and a visual landing is much easier than an instrument landing at a site you are not familiar with and Blacksod is a small pad, surrounded by walls and buildings. 200ft was too low to start, as we know now. The lighthouse light on BlackRock was downgraded years ago to be solar powered, and it's intended for shipping in non fog, so unlikely they could have used it or seen it in bad weather.

In terms of sat Nav, terrain warning etc, as said it often does not have details at very low levels. They are not designed for search and rescue 200ft flights, they are often designed for light aircraft which maintain high minimum heights except when about to land at a proper airport which typically would not have obstructions. Another issue may be memory card capacity. Some of these systems may be a 30 year old design, aircraft certified and may not have gigabytes of memory. They physically cannot store every high point above 200ft on the earth. Maps may be limited to UK/irl or Europe only, and may only reliably include things above 500ft. When you go below 500ft you take your chances.

In terms of time to turn the chopper, remember choppers move very fast, a "back seat driver" mentions something over internal Comms, they discuss it and what it means, they don't realise the distance away and the urgency, they start to turn, but fractionally too late. You need to confirm direction changes, you don't want to turn towards the obstruction.

I really think the whole navigation system is of very limited use below 500ft, I think the minimum altitude should have been tied into waypoints, and used in an idiot proof way. It sounds like these semi official refuelling sites like blacksod are not as well structured or documented compared to proper airports.

I don't really understand the big benefits of top cover. If it's just to relay radio comms, I would have thought a satellite telephone would be reliable and better than relaying messages over radios. If it's to have another chopper in the area, fully fuelled to take over or support main chopper down, I can understand.

My heart goes out to all involved. I suspect similar SAR in other countries have similar problems at low level flights. I know this job is dangerous, from getting knotted up into fishing boats, but really this event could have been avoided.

jpfahy

Was it not mentioned early in the investigation that one of the crew had seen an obstacle on another navigation device in the aircraft. He shouted a warning to the pilot twenty seconds before the crash but his warning was ignored??

zg3409

https://www.boards.ie/discussion/comment/118123468#Comment_118123468

Read the report. The warning was not ignored, there was a delay from warning to turning, while direction was confirmed

Alun

https://www.boards.ie/discussion/comment/118123208#Comment_118123208

I know that, but it all depends on where those reference points fall in relation to the highest point on the island. In other words, suppose that the highest point falls exactly in the middle of a 90m x 90m square, then the highest elevation calculated from the DTM is going to be interpolated from 4 points at a distance of 45 * sqrt 2 = 64 m from that central point. Depending on the exact topology and the interpolation algorithm used that could be very different from reality, not even taking into account any inherent errors in the original data.

Google Earth uses the same DEM data, go here and move the cursor over the island and look down in the bottom right corner at the reported elevation ...

https://earth.google.com/web/%4054.06670723%2C-10.31794499%2C7.790251a%2C1666.33422221d%2C35y%2C0h%2C0t%2C0r

As a further example from my own back yard, the reported elevation of Lugnaquilla is about 10m lower than it actually is, whereas the Sugarloaf near Bray is about 55m lower. The difference is that Lug is a fairly flat topped mountain whereas the Sugarloaf is much steeper and, for want of a better word, "pointy" peak.

MrMusician18

https://www.boards.ie/discussion/comment/118123391#Comment_118123391

I would expect the report to say what errors were made by the crew if any and how they formed part of the outcome, and for them to appear in the conclusions. I don't see anything in the report that identifies a faulty decision made by the crew (beyond vague trapped and unstrapped errors) at that all played a part, let alone one that was the result of fatigue.

All the report says was "mistakes were made". That doesn't help anyone if they cannot identify them and what role they had.

But perhaps I might expect too much from the report.

I haven't read it all though, so maybe it does have those answers within it.

markpb

https://www.boards.ie/discussion/comment/118123620#Comment_118123620

I would imagine it is hard to say specifically which errors, if any, were caused by fatigue. Better rested, perhaps they would have paid more attention to the notes about obstacles along the route or perhaps been more aware of the danger they posted. Perhaps they would have been quicker to respond to the call from the rear crew. It's impossible to know what was going on in their tired heads and the AAIU don't know either so they're not going to say anything that could be wrong and wouldn't be helpful. What is important is that people doing a very difficult job were doing it on a stupidly low amount of sleep.

FishOnABike

https://www.boards.ie/discussion/comment/118123468#Comment_118123468

No. It's clear from the transcript that avoiding action was taken based on the warning from the rear crew member. The heading had been changed but, given the closing speed and size of the obstacle there was not sufficient time to avoid the collision.

MrMusician18

https://www.boards.ie/discussion/comment/118123677#Comment_118123677

I wouldn't expect the report to say crew error X was caused by fatigue. The aaiu couldn't reasonably come to that conclusion, I agree.

However I would expect the report to identify the particular relevant crew errors (if any) and identify them as contributory factors as a separate point as well as fatigue.

Just saying they were tired, but not identifying the decisions that could have been made due to tiredness seems like an obvious omission.

Furze99

https://www.boards.ie/discussion/comment/118123560#Comment_118123560

Without wishing to draw out the point, an island of approx 400m x 300m should have what, maybe at least 10 elevation points measured on it with a random 90m grid. Looking at photos of this island, even if no data point was near the actual summit, it looks like the adjacent ones would have been recording 50-60m above sea level at least. I think the problem is probably that the data was recorded by the Russian or NASA satellites/ shuttle but excluded from the final data as too far offshore. Hasn't the Pacific many small islands, possible that many of these are excluded too to save space. After all 2/3rds of the earth is water which is theoretically level, so no point in using up large amounts of memory with blank data. I think this is how these things work but who knows, maybe the American, Russian and Chinese military have access to full datasets for their own purposes. And just release edited versions for other use, bit like the selective availability or whatever it was called for GPS signals a while back.

MrMusician18

https://www.boards.ie/discussion/comment/118123838#Comment_118123838

When they say russian military maps, I wonder if it's the old Soviet red atlas. For many parts of the world, those old maps are still the most accurate, notwithstanding the omission here.

Alun

https://www.boards.ie/discussion/comment/118123838#Comment_118123838

This is a dump of the raw data at the location of Blackrock island.

I have seen other anomalies with this data where measurements on very steep sided mountains or near vertical cliffs have crazy values. Maybe the radar waves were bounced off at an angle and caused the errors, I don't know. There's a vertical error of no more than 16m inherent in the way the measurements were taken also.

When the SRTM data was being gathered, the US was scanned at a higher resolution (30m), but even that data is publicly accessible and not restricted in any way.

jmayo

https://www.boards.ie/discussion/comment/118122996#Comment_118122996

I asked this before, but no one here has ever answered.

And trust me I am not the only one asking it.

What the hell were they doing at 200ft nearly 16.5km from their landing point ?

They would have to transit at this height for around 10 miles to get into Blacksod.

All the talk of maps would have no bearing on this if they were not flying around at that height 10 miles from their putdown point.

Was this part of an old SOP for S61s or something because it comes across as strange to actual seasoned pilots to be doing this in a modern S92.

Was this answered in the report ?

beanian

Seems like it's a preprogrammed SOP

The APP1 mode on the helicopter’s AFCS is designed to descend the helicopter to 200 ft over 

the water. Pilots can interrupt APP1 and automatically level the helicopter at any other 

intermediate altitude between 2,400 ft and 200 ft. However, OMF gave clear instructions to 

crews that ‘Maximum use should be made of automation and SAR approach modes.’

StevenToast

What was the 282 ft obstacle????

A comment on Newstalk this evening didn't sit well with me. The man being interviewed, don't remember the name, said a crewmember at the back of the craft spotted terrain approaching via an infa red screen he was observing, he informed the pilot and the pilot began turning the craft.

He then said the pilot began the manoeuvre 'but not with any great urgency, because the crewmember hadn't expressed any great urgency in his message'.

What is going on with that narrative? It's as if the media will never dare critisise the pilot, even to the point of blaming the winchman.

FishOnABike

Travelling at 166kmh and towards an obstacle 550m away there's not time to do much about it. You can't beat the laws of physics.

FFVII

Always expected this to have been all easily avoidable and yep, they knew for years and did nothing.

Same old, same old.

https://www.irishtimes.com/news/politics/oireachtas/culture-of-bullying-widespread-across-coast-guard-d%C3%A1il-told-1.4719818?mode=sample&auth-failed=1&pw-origin=https%3A%2F%2Fwww.irishtimes.com%2Fnews%2Fpolitics%2Foireachtas%2Fculture-of-bullying-widespread-across-coast-guard-d%25C3%25A1il-told-1.4719818

This aswell^

They all need to go. Theirs a name for it, where you fire the whole lot of them, from the US, cuz thats what they think they need to do with the cops there. Gradually fire them all.

Same needs to be done here. In most public bodies, not just in this one.

markpb

https://www.boards.ie/discussion/comment/118124942#Comment_118124942

Are you sure they were at that speed? There’s a diagram showing AIS locations and timestamps in the full report and, without doing a proper calculation, the speed looks a lot lower than 166km/h.

plodder

https://www.boards.ie/discussion/comment/118124787#Comment_118124787

You can check the transcript of the voice recording. It's in the interim report. I presume it's in the final report as well. The description above is accurate and it's not blaming the pilot or the winchman, because neither of them knew they were approaching a 280 foot rock at that point.

irishgeo

https://www.boards.ie/discussion/comment/118123468#Comment_118123468

It wasnt ignored the instruction was keyed into the flight computer but not fast enough for it to turn. Read the CVR transcript

They were flying low because of low cloud.

So the first waypoint the auto pilot was aiming for actually started straight after a 700ft high island that wasnt in the terrain map.

FFVII

Why were they doing 17hrs? Not their fault.

Poor management. Jail all them lads. Make the next lot take responsibility for the big bucks they are on instead of sitting on their hole bullying everyone.

Negative_G

There is some confusion developing here.

The aircraft and crew may well have been sporting IRCG insignia but they were under the employment and ownership of CHC Ireland.

The bullying issues recently reported in the media are not associated with this incident.

CHC and the IAA are the two stakeholders have the most to answer from this report, in my opinion.

Don't forget, there will very soon be a 600-700 million euro contract up for tender soon and no doubt CHC Ireland will be competing for it once again.

As was mentioned multiple times in the report, as soon as a service is commercialised, safety becomes a secondary consideration. The commercial pressure takes over and those not on the front line are the ones driving the organisational pressure to deliver. It's a toxic circle.

FishOnABike

https://www.boards.ie/discussion/comment/118125112#Comment_118125112

The rte report https://www.rte.ie/news/ireland/2021/1105/1258054-r116-report/ says they were travelling at a ground speed of 90knots. That's just over 166kmh.

"The investigation concluded that the first indication the crew had about the obstacle in their path was when Winchman Smith announced he had detected an island on the infra red camera, when the helicopter was about 0.3 nautical miles (550 metres) from it, travelling at a ground speed of 90 knots."

https://www.boards.ie/discussion/comment/118123723#Comment_118123723

I used to work in medical negligence litigation and believe me, fatigue drains your ability to function highly in complex situations far more than what most of us know to be tired at work. I've even had colleagues comment that the most important question to ask any doctor, before they do a complex task, is when did they last sleep. the expert who is well rested is not the same expert with fatigue. That's not to blame the crew but reaction times and decision making degrade under fatigue, it probably wouldn't have made a difference here but we'll never know. Work practices for complex jobs should have maximum wakefulness periods before a person is pulled off the job as a matter of course.

That applies across the board btw, something like less than 1% of people can function well when fatigued, iirc. chances are you and I, and the crew, are (or were) not in that 1%.

We can't know what errors were made due to fatigue because we've no accurate, non-fatigued, case to compare it to. It's just a general comment that the crew were awake too long before the mission started.

MrMusician18

https://www.boards.ie/discussion/comment/118125862#Comment_118125862

I think you might be missing my point. This wasn't a general comment by the aaiu, it was in the contributing factors for the accident. I fully agree with you that tiredness can impact performance negatively and severely. That is well established and I fully accept that.

The issue is that in the contributing factors in the report, no decision, action or lack of action that the crew took is identified that one could reasonably say that was a result of tiredness. In fact, none of the crew decision making really appears in the contributory factors.

The fact they were tired is worth noting of course, but is somewhat irrelevant if no decisions they took, let alone ones they took due to tiredness are contributing factors to the accident. If a driver is hit by an asteroid on the way home, is the fact that he's tired relevant? If the report is saying they crashed because cloud was low and the obstacle was unmarked on their nav system, not because their reaction times were low, or there was a loss of situational awareness or similar, is tiredness really a factor?

Me2U2

https://www.boards.ie/discussion/comment/118125232#Comment_118125232

Around page 262-264 it suggests they seem to have relied on the general notes having significant obstacles and says that crews may have tended to avoid tabulated information in favour of plain text notes. It also says if the normal aircraft approach checklist had been used it would have prompted them to check the obstacles table. They were using the DVE Approach which CHC said was ‘normal’ but which the AAIU decided was for SAR operations at sea and was probably not appropriate for a landing on a helipad.

I haven’t found a section yet which says whether Black Rock was actually listed correctly in the table for the approach they were using,

https://www.boards.ie/discussion/comment/118121129#Comment_118121129

This would imply that the crews in general accepted working under uncertain standards in that various notes obstacles may or may not exist, and in-noted obstacles may be present. Why there wasn’t insistence on reconnaissance missions in daylight conditions of good visibility to verify uncertain data in one way puzzles me, but on a human level they were just trying to get on with their very busy jobs.

Ryaner

https://www.boards.ie/discussion/comment/118125999#Comment_118125999

There was a project in CHC to do exactly that, the report highlighted it and stated on pg66

"""

In July 2013, there was a proposal to record all routes that had been test flown; to update the index page on the Route Guide to state whether or not a route had been test flown; and to add a notice to the index page stating that ‘No crews are allowed to use routes at night or in poor visibility unless indicated here that they have test flown’. Emails also suggested that a list of all routes in each area [Base] was to be developed and displayed on the Ops Room wall, along the lines of; ‘Route’, ‘Date Test Flown’, ‘By Whom’ and any ‘Comments’. The Operator’s Safety and Quality Integrated Database (SQID) system (Section 1.17.4.2) had the potential to provide a means to record and track the actions associated with the Route proving task. The Investigation notes that the associated email chain involved several pilots, including a Post-Holder; however, SQID was neither used nor suggested for this purpose. 

Whilst the emails reviewed seem to indicate committed efforts by a number of persons at all bases, there was no one individual/Post-Holder responsible for driving the project and none of those involved had been trained for this type of work. Four years after the Route Guide transposition, the document still contained the warnings ‘It is a work in progress and should be used with the necessary caution until all routes/waypoints are proven ... Again it is a work in progress so if you have any comments/suggestions, please revert’.

"""

Ryaner

https://www.boards.ie/discussion/comment/118123620#Comment_118123620

It is really really important for these reports not to apportion blame, so much so that every report will say so and reference the central guidelines about it. What is important is to identify the root causes so that they can be fixed.

If, and I'm not saying the crew did make a mistake, but if they did, it is very important to establish why they did. A whole lot of accident reports over the years have found crew making mistakes and then identified the organisational issues that actually created them. Crew Resource Management that exists in all modern airlines is one such thing that came out of this way of thinking. A good litmus test tends to be if you put another crew into the same situation at the same time, would the outcome have been different. IMO the answer is we'd have the same outcome.

I haven’t had the time to read the report as I’ve been extremely distracted, but will settle down to read through it at some stage where I can focus.

Furze99

https://www.boards.ie/discussion/comment/118123916#Comment_118123916

The Russian data referred to was not physical or digital forms of physical maps. If you ever play games with 3D graphics, you'll see modelling of the ground and so on. These are based on digital models of the landscape, imaginary usually in games. In real life, there are digital models of the land surface. On a planetary wide basis, these were/are measured by the big players - NASA, Russians, Chinese presumably, EU. This type of data was loaded in the R116 navigation system to predict and give warning of heights in the line of flight. It seems that Black Rock was missing in the Russian datasets and possibly also in the NASA datasets, too far off the coast to be included seems to be the reason.

mickdw

https://www.boards.ie/discussion/comment/118124942#Comment_118124942

I believe there was time.

The flying pilots were warned of an obstacle up ahead and told to go right. A new heading was entered into flight computer but they hit before this took effect.

If the flying pilot was made aware that this was a life or death situation, surely she had the option to manually take control and take the chopper high and wide on full power.

The entry of a revised heading into flight computer tells me that no emergency action was taken. No extra power put in etc.

AnRothar

I believe there was time.

160 kmh is 160000 meters per hour.

Divided by 3600 gives a forward speed of 44 meters per second.

550 meters of ground at 44 meters every second is just under 13 seconds.

I am not so sure.

mr.anonymous

Still working my way through the report.

I would say a pilot is used to trusting their instruments and automation above anything else. It's not up to the rear crew to fly or navigate the aircraft and perhaps easy to see why their input might be seen as lower priority than information (even if wrong) on the cockpit displays.

42 safety recommendations points to there being many factors in many organisations that need to be addressed. Don't think other AAIU reports have come near that number.

MrMusician18

https://www.boards.ie/discussion/comment/118126646#Comment_118126646

"A good litmus test tends to be if you put another crew into the same situation at the same time, would the outcome have been different."

The problem with the report though, is that it doesn't let us establish that, and that's why this report (or at least it's conclusions) is a failure. By throwing fatigue into the mix, the conclusions suggest crew decision making had a role in the accident (as that is what is impacted by fatigue), but fails to identify what those decisions were.

The fear of apportioning blame shouldn't prevent the reporting of fact. If the decisions of the crew contributed to the accident then it should be stated clearly in the conclusions as well as identifying fatigue. If the decisions of the crew had no role, then fatigue is not a factor and shouldn't be considered a contributing factor, but additional information.

I feel like I'm labouring the point here, but it's important: At the moment we're left with a report that says that there were errors and judgement lapses on behalf of the crew due to tiredness, but nothing on what those were or the role they played in the conclusions. Either they did or they didn't have a role and the report should state it clearly and not have the reader undertake guesswork, or read between the lines.

The report spent far too much time with the lawyers tbh.

FishOnABike

https://www.boards.ie/discussion/comment/118126938#Comment_118126938

Avoiding action was advised and taken within seconds of the obstacle being identified.

The pilot + co-pilot were flying on instruments. Where do you fly towards on full power when you can't see what you are trying to avoid? You could just as easily be powering blind into the obstacle faster and harder.

A helicopter weighing between 8 and 12 tonnes, and travelling at 166 kmh doesn't turn on the spot either. There's considerable inertia to overcome and a flight envelope to consider.

Blackrock was only visible to the rear crew member on the forward looking infra red thermal imaging camera. This would have had very much restricted field of view, contrast, visual acuity and depth perception compared to normal daylight human vision. Given the limitations of FLIR the immediate criticality of the situation may not have been aparent until it was too late.

Add the perception - response time, time to communicate the hazard and corrective action to the pilot + co-pilot, time for the pilot + co-pilot to apply that corrective action (whether through instrument settings or switching to manual flight control) and the time for the helicopter to respond to that corrective action and you run out of time very quickly. The collision makes it self evident that in the circumstances, there wasn't time.

markpb

https://www.boards.ie/discussion/comment/118127836#Comment_118127836

You could be reading too much into it. The crew were fatigued and fatigue is known to cause problems so the investigation unit recommended that crew fatigue should be better managed. I didn’t see anywhere in the report that said crew fatigue was a factor.